We commend the authors of the recently published ISAR-TRIPLE (Duration of Triple Therapy in Patients Requiring Oral Anticoagulation After Drug Eluting Stent Implantation) clinical trial on their efforts (1). The trial adds valuable information to the ongoing debate of antiplatelet and anticoagulation management in patients on chronic oral anticoagulation who undergo coronary artery stenting; however, we would like to address several important points:

1. The authors mention that the clopidogrel loading dose was 300 mg to 600 mg, but they do not mention specific data about the loading dose in each of the treatment arms. Given the numerically higher periprocedural myocardial infarctions observed in the 6-weeks group, could a preferential lower clopidogrel loading dose have affected this outcome? It would be interesting to know such data, as well as the repeat revascularization data.

2. There are no data about the prevalence of chronic kidney disease in each of the 2 treatment arms. Chronic kidney disease patients are prone to a higher risk of bleeding, and thus it is important to know whether such data could have affected the results.

3. The decision to present 9-month data as opposed to longer follow-up, especially with the relatively small sample, raises questions about the power of the study to depict differences in ischemic outcomes.

In conclusion, the optimal duration of triple therapy is a question that remains unanswered, and for now, mostly relies on physicians weighing the ischemic versus bleeding risk with short compared to extended duration of therapy. A large, randomized trial comparing these various treatment options is needed.

Footnotes

Please note: Dr. Shavelle has received research grants from Zoll Medical, Abbott Vascular, St. Jude Medical, and Neostem; and is on the speakers bureau of Maquet, Medtronic, and St. Jude Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

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